Community Assistance Request Form

Drumright Dental Center Loves Giving Back to Our Community!

Here at Drumright Dental Center, we are very proud of our ability to contribute and to be of service to the community around us. If you are in need of a speaker, educational materials or other assistance with your event, please contact us using our Community Assistance form below. Once we receive your request, we will reach out to you to see how we can best help!

Use the form below to request speakers, materials and other donations related to community events.

Assistance Request

Name of Organization *

Organization Address

Mailing Address

Address Line 2

City

State/Province

Zip/Postal

Country

Name of Contact Person *

Please enter the Point of Contact.

Name of Alternate Contact Person *

Description of your Event *

Please include who will benefit and how from your request or event

Upload Materials

Maximum file size: 2.1MB

If you have materials related to your request, please them here. These might include flyers, logos, letters, etc.

Date of Event

If your request involves an event, please enter the date and time.

Time of Event

Location of Your Event

Street Address

Address Line 2

City

State/Province

Zip/Postal

Country

If your request involves an event, please enter its location.

Email Address *

Phone Number *

Yes, Please Sign Me Up!

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Please note that e-mail is not a secure form of communication. Medical information placed here may not be confidential. Please use this form to send your contact information, and we will respond to your inquiry using a secure method. This form should not be used by children under the age of 18.

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